* 1) Complete lines 1– 16 below in full, 2) Print & sign both pages, & 3) Fax or mail one completed form to: 
  Columbia Review Main Office, Home Study Enrollment, 811 Oregon Avenue, San Mateo, CA, 94402-3307, USA
  Registrar's Fax: 1-650-348-MCAT (-6228);    Phone: 1-650-343-0309 or 1-800-300-PREP  

Columbia MCAT Review is an independent intensive MCAT preparation and medical school 
admissions assistance program run by medical professionals for pre-medical students. 
The program is not run by or affiliated with an undergraduate university or medical
school.  The Intensive Home Study Course has been carefully designed to teach and 
review important concepts and skills needed for the MCAT exam.  Please make use of
all of the course materials: comprehensive review notes and studyguides, strategy 
handouts, review question and passage-format practice exams, and admissions 
assistance materials.  You will get out of the course what you put into it. Since
student motivation, study habits, skills and aptitudes differ, Columbia Review 
cannot make a warranty as to student skill development or future test results.

All course materials are for your personal MCAT preparation use only and cannot be
shared, given, sold, or shown to any other person at any time.  All course materials 
are owned and copyrighted by Stephen D. Bresnick, M.D., Director of Columbia Review,  
and are protected under federal copyright laws.  Course materials cannot be  
reproduced in any form, by photocopy, microfilm, or any other means, or incorporated 
into any information system, electronic or mechanical, without the written 
permission of the copyright owner.  Since honor and integrity are expected of those 
entering medicine and of all Columbia Review students, failure to comply with any of
these material use rules may result in the notification of federal and/or local 
legal authorities, medical school officials, the Association of American Medical 
Colleges (AAMC), as well as possible criminal and civil legal action.

The tuition for the complete MCAT Intensive Home Study Course is $325.00 (this
includes all course MCAT Prep Books and orientation). The total shipping and 
handling fee within the USA is $35.00 (all materials sent 2-3 day "Priority" delivery). 
Individual books can be bought separately (Book 1 priced $150.00, others $75.00 each)
plus $10.00 each for "Priority" shipping.  There are no refunds or exchanges
for any reason once your application has been accepted and processed by us.

Please complete Lines 1 - 16 below (completion of all lines is required):

1) Your name: 

2) Your e-mail address: 

3) Your current home address: 

4) Full shipping address: 
  
5) Your current phone:    Parent/Permanent: 

6) Your University: 

7) Your Major, & Grad date: 




                YOU MUST SIGN HERE: X_______________________________ DATE:__________

PAGE ONE OF TWO

8) When will you take the MCAT: 

9) When will you apply to medical school: 

10) Previous MCAT taken: 
   (if yes, when, scores & how prepared):

11) What is your weakest MCAT subject area: 

12) How did you hear about our program: 

13) Method of payment:
    Check or Money Order (payable to Columbia Review, mail with Application)

    Visa  MasterCard  Discover  American Express
    Card Holder's Name: 
    Card #:  Expiration Date: 
    Security Code (3 or 4 digits): 

    Full Address Monthly
    Statement Mailed to: 

14) Total Charges:
                 i) Complete MCAT Intensive Home Study Course @ $325.00

                ii) Individual Book(s)#        Total Price = $ 

               iii) Shipping & Handling fee (as per above charges)    = $ 
               ______________________________________________________________________

                iv) Total Amount Due & Paid                           = $ 

15) Application for Enrollment Agreement 
    (Print completed form, Sign, Date, Fax or Mail to us):

  ALL OF THE INFORMATION I PROVIDED ABOVE IS TRUE AND CORRECT.  I BOTH COMPLETELY UNDER-
  STAND AND PROMISE TO ABIDE BY THE ABOVE TERMS OF THIS TWO PAGE ENROLLMENT AGREEMENT.
  I ENCLOSE MY PAYMENT FOR ALL MATERIALS AND SHIPPING/HANDLING FEES IN THE FORM CHECK
  MONEY ORDER OR AUTHORIZE PAYMENT BY THE CREDIT CARD INDICATED ABOVE IN ITEM 13.

  Student Signature in Ink: X___________________________________________________

16) Today's Date: 

*************************************************************************************
NOTE: Materials will be shipped upon our receipt of this completed & signed form  
via FAX or MAIL and payment of total amount due.
 
Fax:    1-650-348-MCAT (-6228)
Phone:  1-650-343-0309 or 1-800-300-PREP (call to enroll or to ask any questions)                                       
Mail:   Columbia Review Main Office, 811 Oregon Ave, San Mateo, CA 94402-3307, USA
*************************************************************************************

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